Remainder of FCM Cases not Covered in Simon Ma's Deck Flashcards
A 25-year-old patient presents to the office for follow-up on anxiety and tobacco dependence. She reports she is doing well on her new medication to help with both her mood and smoking, though she continues to smoke. She recently started her first sexual relationship with a new female partner. She received a tetanus vaccine at the age of 18, and she received her flu vaccine this year. Her blood pressure is 122/70, and her physical exam is within normal limits. You review her recent Pap test, which was negative. Which of the following indicates the vaccines she should receive today?
A. HPV vaccine alone
B. HPV vaccine and pneumococcal conjugate vaccine (PCV13)
C. HPV vaccine and pneumococcal polysaccharide vaccine (PPSV23)
D. HPV vaccine and Zoster vaccine
E. No vaccines are needed
The correct answer is C.
She should receive both the HPV vaccine and the pneumococcal polysaccharide vaccine (PPSV23).
The pneumococcal polysaccharide vaccine (PPSV23) is recommended for adults who smoke (like this patient); have chronic heart, lung, or liver illness; have alcohol use disorder; and have diabetes. The pneumococcal conjugate vaccine (PCV13) is not routinely recommended for adults, though it can be given to some patients at the age of 65.
A 72-year-old female with a 30-year history of type 2 diabetes and hypertension returns to your office for a routine visit. She is taking 20 units of insulin glargine every morning and five units of insulin aspart with meals. She is on atorvastatin 40 mg daily and lisinopril 40 mg daily. She is on no other medications. Her A1C is 6.5% and her BP today is 145/90. She notes blurry vision for the past several months and a few days of dark spots in her vision. She denies headaches or nausea. What is the most appropriate next step to slow down the progression of diabetic retinopathy?
A. Increase her insulin aspart from five units to seven units with meals.
B. Increase her insulin glargine to 23 units every morning.
C. Perform a fundoscopic examination and make no changes to her regimen today.
D. Start her on a baby aspirin.
E. Start her on a calcium channel blocker.
The correct answer is E.
The patient’s symptoms describe diabetic retinopathy which affects 40% of people with diabetes who are on insulin after five years (25% of those on oral agents). Proliferative retinopathy is prevalent in 25% of the diabetes population with ≥ 25 years of diabetes, but many patients have retinopathy much earlier. Patients with diabetes need to see an ophthalmologist regularly for a dilated retina exam and should not rely on an undilated fundoscopic exam by a primary care physician (C) as effective screening. Increasing either her mealtime insulin (A) or her basal insulin (B) would be inappropriate, as her hemoglobin A1C is at target. Aspirin (D) has not been demonstrated to have an impact on diabetic retinopathy. This patient’s blood pressure is above her target of 130/80 mmHg. Starting her on any of the first-line options for blood pressure management, such as a calcium channel blocker (E), would be appropriate. There is fair evidence that in addition to decreasing cardiovascular risk, blood pressure control may prevent progression of diabetic retinopathy.
You are seeing a 55-year-old male who presents to the family medicine practice with a two-week history of daily episodes of sudden lightheadedness and palpitations. These seem to occur without provocation and last for approximately five minutes each time. He has not passed out during these episodes, but he has felt the need to sit down when they come. Sitting calmly and waiting seems to make them go away. He reports no chest pain, diaphoresis, jaw pain, or arm pain with these episodes. He has a past medical history of gout and hypertension, for which he takes daily allopurinol and losartan. He does not smoke or drink. He is not under any recent stresses at home or work. On exam, he is in no acute distress. His vital signs are completely normal, as is his cardiopulmonary exam. A recent complete blood count and TSH were normal.
Which of the following is the most appropriate next step?
A. Order a 48-hour Holter monitor
B. Order an echocardiogram
C. Order an exercise stress test
D. Reassure him that his palpitations are likely benign and that he should focus on a healthy lifestyle
E. Transfer him to the emergency department for admission to the hospital
The correct answer is A.
This patient is experiencing frequent palpitations that are symptomatic enough to make him lightheaded and need to sit down. Given his description of his symptoms and his normal exam, episodic arrhythmia is the most likely cause of his symptoms. As such, a 48-hour Holter monitor (A) would be the most appropriate test. He is having daily symptoms, so a longer-term loop monitor is not needed in this situation.
Echocardiography (B) and cardiac stress testing (C) would be appropriate tests to evaluate for coronary artery disease or congestive heart failure. These are less likely explanations of his current symptoms than an arrhythmia. Reassuring him that these episodes are benign could risk missing an important diagnosis (D). The patient is perfectly stable and is not having symptoms or findings at the time of the visit, so referring him to the ED (E) is not appropriate.
A 52-year-old female with a history of diabetes and rheumatoid arthritis presents for her annual examination. She works in an office 10 hours a day and rarely gets exercise. Her BMI is 23 and her blood pressure is 152/85. Her previous visit two months ago showed blood pressure of 148/82. Her father had a history of diabetes and her maternal grandmother died of rheumatic heart disease at the age of 42. She admits to marijuana drug use in the past and is a nonsmoker. Which of the following is a major risk factor for coronary heart disease (CHD) that this patient has?
A. Age B. Family history C. Hypertension D. Obesity E. Rheumatoid arthritis
The correct answer is C.
With two elevated blood pressure readings, this patient meets the criteria for stage 2 essential hypertension (C), which is one of the major risk factors for CHD. Other major risk factors include diabetes (which this patient has), smoking, and elevated lipids. These data points, which are included in the ASCVD risk tool, capture most of the variability in a patient’s risk for CHD.
Age (A) becomes a risk factor over age 55 for females and 45 for males. The family history (B) becomes a risk factor if a first-degree relative has CHD male < 55 and female < 65. This patient is not obese (D).
This person also has other risk factors for CHD, but ones that are not included among the major risk factors. These include her sedentary lifestyle and her rheumatoid arthritis (RA). RA (E) and other inflammatory conditions increase a patient’s risk of CHD, but to a lesser extent than the major risk factors.
A 59-year-old patient comes to the local ER with a swollen, tender knee that started yesterday. He returned home two days ago from a five-day hike on the Appalachian Trail. He reports no recent or previous injury to the knee and any history of previous inflammatory joint disease. Vital signs: temperature is 36.5 C (97.7 F), pulse is 80 beats/minute, blood pressure is 139/75 mmHg, and respiratory rate is 22 breaths/minute. His lower extremities are marked with abrasions in various stages of healing. He holds the knee in full extension. The knee is swollen, reddened, and tender, and it feels warm. Which of the following is the most appropriate next step?
A. Knee aspiration
B. Magnetic resonance imaging (MRI) of the knee
C. Prescription for colchicine
D. Prescription for full-dose acetaminophen
E. X-ray of the knee, including sunrise and standing films
The correct answer is A.
This patient is presenting with an acutely inflamed knee, which could represent an initial presentation of an inflammatory rheumatalogic disease such as rheumatoid arthritis (less likely), gout, or a joint infection. The latter diagnosis can be rapidly destructive of the joint and needs to be ruled out urgently with a joint aspiration and fluid analysis. This would also help distinguish between infection and gout. Knee imaging would be useful for identifying bony (X-ray) or soft tissue (MRI) pathology, but would not determine if this patient has a septic joint. Colchicine is a treatment for gout that would only be appropriate if this condition had been definitively diagnosed.
You are seeing a 19-year-old female who suffered a knee injury playing soccer one day ago. The injury involved a sudden deceleration in which she planted her right foot in front of her while running, whereupon another athlete fell against her shin. She felt a pop and sudden pain. She had to be helped off the field and her knee swelled immediately. Today, she reports that she has considerable right knee pain with bearing weight and that her knee feels unstable at times. Her past medical history is unremarkable, and she takes no medications. On exam, her vital signs are perfectly normal. You conduct a knee exam.
Which of the following exam maneuvers is most likely to be abnormal in this patient?
A. Lachman test B. Laxity to valgus stress C. Laxity to varus stress D. McMurray test E. Posterior drawer test
The correct answer is A.
This patient most likely has experienced a tear of her ACL, which can often happen with a sudden deceleration injury. Patients typically describe a “popping” sensation when the injury occurs. Common exam findings for a patient with an ACL tear include a positive anterior drawer test and a positive Lachman test. Laxity to varus (outward) stress would suggest a tear of the lateral collateral ligament, which is a relatively uncommon sports injury. Laxity to valgus (inward) stress would indicate a possible tear of the medial collateral ligament. This can sometimes co-occur with an ACL tear and is a possible finding in this patient, though it is not the most likely finding. McMurray test is positive in the setting of meniscal tears.
You are seeing a 62-year-old male with a history of osteoarthritis in his knees and well-controlled hypertension and chronic constipation. His arthritic pain has been disabling in recent months, making it very difficult for him to do his work as a plumber. He has tried full dose acetaminophen in combination with diclofenac, but he still reports 8/10 pain and stiffness. He would like to pursue other treatment options. His current medications include chlorthalidone, diclofenac, acetaminophen, and methylcellulose. On exam, he is in no acute distress and his vital signs are normal. His knees show no warmth, erythema, or gross deformity. They are stable to varus and valgus stress. The Lachman test and McMurray test are both normal. There is moderate crepitus bilaterally.
Which of the following would be the most appropriate next step in the management of his pain?
A. Prescribe a glucosamine sulfate and chondroitin sulfate combination pill
B. Prescribe amitriptyline nightly
C. Prescribe oxycodone after reviewing a pain management agreement and performing a urine drug screen
D. Refer to physical therapy for strength and mobility training
E. Schedule for bilateral intra-articular hyaluronic acid (viscosupplementation) injections
The correct answer is D.
There is clear evidence that exercise self-management programs, typically guided by physical therapists, help with osteoarthritis pain and stiffness. Tricyclic antidepressants can play a role in chronic pain management in appropriate patients, but they cause significant constipation. This would not be an appropriate choice for this patient, who takes a medication for chronic constipation. There is consistent evidence that glucosamine sulfate and chondroitin sulfate (alone or in combination) have no appreciable impact on symptoms from osteoarthritis and should be avoided. The same is true for hyaluronic acid injections. Chronic narcotics can play a role in the management of pain in selected patients, but they should only be considered after all safer options (e.g., physical therapy) have been tried first.
A 64-year-old male comes in for a routine physical examination. He notes that over the past few months he has had to get up to urinate in the middle of the night. Benign prostatic hypertrophy (BPH) is on your differential. What other symptom is consistent with BPH?
A. Cloudy penile discharge B. Erectile dysfunction C. Hematuria D. Urinary urgency E. Dysuria
The correct answer is D. Urinary urgency is a common symptom of BPH.
Cloudy penile discharge is more consistent with urethritis, prostatitis, gonorrhea or chlamydia.
Erectile dysfunction: this differential is wide, including psychosocial, endocrine, vascular, structural, medication side effect, chronic disease. While symptoms of BPH might influence dysfunction, it is not a primary cause.
Hematuria would be more likely in infections, urinary tract or kidney stones, trauma or cancer.
Dysuria can be related to a UTI, STI, topical or systemic irritant, and is uncommn in BPH.
A 57-year-old female comes in, concerned about a 1.5 cm dark multicolored mole lateral to her left eye that has been increasing in size over the past six months. A punch biopsy shows pathology indicative of squamous cell carcinoma. What is the most appropriate intervention?
A. Three-month follow-up visits for the first year; then every six months
B. Avoid artificial sources of UV light, such as indoor tanning
C. Cryotherapy extending 4 mm beyond the lesion margins
D. Mohs surgery
E. Excisional biopsy extending 5 mm beyond lesional border
The correct answer is D.
Lesions that are close to facial features such as the eyes and in cosmetically sensitive areas are best treated with Mohs surgery because it is tissue sparing and has better cosmetic results. A punch biopsy is done for diagnosis. It would not be effective at getting the required 4 mm margins so the patient would need further intervention before going to surveillance. Treatment with 5-FU or cryotherapy is not indicated for squamous cell carcinoma. Excisional biopsy is a potential treatment, but it would require removal of a large area of tissue in a cosmetically sensitive area and may require additional surgery if the margins are not clear.
A 34-year-old male comes to the clinic complaining of recurrent abdominal pain. He says the pain has been bothering him for the past eight months. He reports episodes of diarrhea and constipation, with more episodes of constipation. He states he has noticed an increase in flatulence. He denies any nausea or vomiting. He has noticed mucus in his stools, but no blood. He states that he cannot recall if anything aggravates the pain, but admits to being under more stress than usual, due to his mother-in-law moving in with him and his wife. Vital signs show a blood pressure of 124/76 mmHg, pulse of 74, respirations of 16, a temperature of 97.9, and oxygen saturation of 98% on room air. Physical exam is unremarkable.
The most appropriate initial step in management is:
A. Scheduling the patient for a colonoscopy to look for colon cancer
B. Discussing the patient’s diet, and educating him about avoiding dairy products
C. Performing a CBC, TSH, complete metabolic panel, and stool studies
D. Offer behavioral therapies and exercise to help with symptoms
E. Scheduling the patient for a CT scan of the abdomen to rule out small bowel obstruction
The correct answer is D.
The patient most likely has a diagnosis of irritable bowel syndrome (IBS). IBS is diagnosed based on clinical history, physical exam, and absence of alarm symptoms suggesting other pathology. The Rome IV criteria are often used to aid diagnosis of adult IBS: Recurrent abdominal pain, on average ≥ 1 day per week in past three months with ≥ 2 of following features: 1) related to defecation; 2) associated with change in stool frequency; 3) associated with change in stool form (appearance). Laboratory studies are not required to make this diagnosis if other diagnoses are unlikely, as in this case. Offering behavioral therapies and exercise to help with symptoms would be appropriate first steps to help with irritable bowel syndrome.
Scheduling a colonoscopy to search for colon cancer is inappropriate, as he is not presenting with bloody stool or significant weight loss. The patient is too young to undergo a screening colonoscopy without a history of a first-degree relative who was diagnosed with colon cancer at an age 10 years older than his current age.
Discussing the patient’s diet is suitable; a trial of avoidance of dairy products would be dependent on history, and a recommendation that includes this strategy may or may not be appropriate.
Scheduling a CT scan of the abdomen to rule out a small bowel obstruction is inappropriate. The patient is not complaining of nausea or vomiting, and has no abdominal tenderness or hyperactive bowel sounds on physical exam, all of which would be suspicious for small bowel obstruction.
You are seeing a 32-year-old female in the family medicine ambulatory practice who presents with concern of fatigue. She finds herself simply exhausted at various points of her day, particularly when she is sitting and having to focus on something. When she is busy and physically active, she notices the fatigue less. She reports no recent weight change, skin changes, temperature intolerance, tremulousness, or unusual bleeding. She uses a levonorgestrel IUD and does not have menses on a monthly basis. Her past medical history is positive for a history of seasonal allergies that are well-controlled with loratadine. She does not smoke, drink or use illicit substances. She works as an emergency department nurse at a local hospital, alternating between evening and over-night shifts. On exam, she is well-appearing and has normal vital signs and a BMI of 24 kg/m2. She has no conjunctival pallor. Her thyroid is non-palpable. Her cardiopulmonary exam, abdominal exam, and neurologic exam are essentially normal. Her affect displays concern about her fatigue, but shows a normal range and she is able to smile and laugh at times.
Of the following, which is most likely to be the cause of her fatigue?
A. Side effects of her medication. B. Iron deficiency anemia. C. Sleep dysfunction due to alteration of her circadian rhythm. D. Hypothyroidism E. Chronic Fatigue Syndrome
The correct answer is C.
This patient most likely is experiencing sleepiness due to her alternating shifts between evening and overnight hours, combined with caring for three children who can be assumed to be awake during daytime hours. Shift work disorder is a well-recognized cause of chronic sleepiness that is most pronounced during periods of less activity and stimulation.
Iron deficiency anemia (B) is less likely in this patient who does not have monthly menses. Loratadine (A) is a non-sedating antihistamine, and it rarely causes significant fatigue. While hypothyroidism (D) is possible in this patient, it is less likely given that she shows no other signs of this disease (e.g. skin or weight changes, temperature intolerance). Chronic Fatigue Syndrome (E) typically presents with fatigue that is made significantly worse by physical activity.
You are seeing a 42-year-old established female patient in the office for her yearly physical. She has a past medical history of hypertension, and she has no significant family history. She is a teacher at a local high school, and she has three school-aged children. She does not drink alcohol or use illicit drugs, but she has smoked a pack and a half of tobacco for the past 20 years. She would like you to order a colonoscopy because a friend of hers was just diagnosed with colon cancer and has passed away from it.
What combination of types of cancer screening all receive an A or B recommendation from the USPSTF for this patient?
A. Cervical cancer screening, lung cancer screening, and breast cancer screening
B. Cervical cancer screening and breast cancer screening
C. Cervical cancer screening only
D. Cervical cancer screening, breast cancer screening, and colon cancer screening
E. Breast cancer screening and lung cancer screening
The correct answer is C.
The USPSTF gives an A recommendation to cervical cancer screening for all women with a cervix from age 21 to age 65. This is the only cancer screening that receives an A or B recommendation for a 42-year-old female.
A, B, D, and E all include types of cancer screening that are recommended in some patients, but not in a patient at this person’s age.
The USPSTF gives breast cancer screening a C recommendation for women between ages 40 and 49, meaning physicians should engage in shared decision making about mammography with patients in this age group.
The USPSTF gives a B recommendation to lung cancer screening (with low dose CT) among patients with at least a 30 pack-year tobacco history (like this patient), but only for ages 55 through 80. This 42-year-old is too young to commence screening, though you should certainly recommend tobacco cessation.
The USPSTF gives an A recommendation to colon cancer screening for low-risk patients between ages 50 and 75. Having a friend die of colon cancer understandably increases this patient’s anxiety about this disease, but does not increase her risk.
Ms. Michaels is an 80-year-old female with a past medical history of shingles. She comes to your office accompanied by her daughter Jennifer who reports that her mother is forgetting things. Jennifer explains that her mother will ask the same question several times throughout the day. Ms. Michaels also gets confused easily and is more passive than usual. Her memory problem was noticed two years ago after she forgot to pay her bills on multiple occasions. Jennifer now pays her mother’s bills and cleans and cooks for her. Ms. Michaels’ vital signs are temperature of 99.2 Fahrenheit, blood pressure of 118/70 mmHg, heart rate of 80 beats/minute, and respiratory rate of 12 breaths/minute. Her physical exam is significant for bilateral osteoarthritis hand deformities. She does not have a tremor, nor jerky uncontrolled movements. She is not on any chronic medications. She has no smoking history and does not drink alcohol. CT head shows mild atrophy of the hippocampus. Her MMSE is 20.
The patient’s diagnosis is most likely associated with?
A. Alzheimer disease B. Huntington disease C. Lewy bodies D. Prion protein E. Vascular disease
The correct answer is A.
Ms. Michaels’ symptoms and CT results are consistent with Alzheimer disease (A). The hippocampus is a critical area for memory retention.
The presenting symptoms of Huntington disease (B) are choreiform movements (random, jerky and uncontrollable movements), which are absent in Ms. Michaels, so this option is less likely.
Lewy bodies (C) are abnormal aggregates of protein that develop inside nerve cells in Parkinson disease and often presents with Parkisonian symptoms, fluctuations in alertness and attention (delirium), and visual hallucinations. Ms. Michaels does not have a tremor so it is less likely that she has dementia caused by dementia with Lewy bodies.
Prion proteins (D) are seen in transmissible spongiform encephalopathies, such as Creutzfeldt-Jakob disease, and are exceedingly rare, so it is less likely in this case.
Patients with vascular dementia (E) usually have cardiovascular risks such as a hypertension, hyperlipidemia, or tobacco use. Ms. Michaels does not have any of these risk factors, so it is less likely.
You are seeing a 92-year-old male in the hospital. He was admitted after a fall in which he broke his hip. It is now post-op day two from surgery to repair the fracture. His children report that he has been very confused this morning, with varying levels of alertness. Yesterday, he had been recovering well and even participated in physical therapy. Today, he does now know where he is and is at times combative with his care team. His medical history is positive only for hypertension. His medications include amlodipine 5 mg daily and morphine 4 mg IV every 4 hours as needed for pain. His vital signs are all normal today, and his general exam is unremarkable except for expected post-operative changes to his hip. He is somnolent during the examination. Today’s labs include a normal CBC and basic metabolic panel. A urinalysis reveals no leukocyte esterase and is nitrite negative.
What is the most likely cause of his current mental status?
A. Acute stroke B. Morphine C. Residual effects of the anesthetic medications from his surgery D. Pneumonia E. Urinary tract infection
The correct answer is B.
Morphine (B) and other sedating medications (such as other opioids, benzodiazepines, anticholinergics, etc.) commonly cause delirium in older patients, particularly after the cumulative effects of repeated doses. Discontinuing the pain medication may not be an option, due to his need for pain control, though reducing the dose and careful attention to the dosing frequency may help minimize his symptoms.
Acute stroke (A), while sometimes the cause of acute mental status change, is unlikely in a patient with no new physical findings to suggest stroke, such as new motor weakness.
Anesthetic medications (C) can cause delirium, however they would be expected to do so initially after they are given. The fact that he did not manifest delirium on post-op day one makes this an unlikely explanation.
Pneumonia (D) is a common cause of delirium in hospitalized patients, but it would be expected to present with fever, elevated WBC count, lung findings, and possibly increasing oxygen requirements. This patient has none of these findings.
A urinary tract infection (E), while common in post-operative patients, is less likely in a patient with a normal urinalysis.
A 67-year-old male comes to the clinic for a health maintenance visit. His past medical history is significant for chronic allergic rhinitis, severe chronic obstructive pulmonary disease (COPD), osteoporosis, psoriasis, atrial fibrillation, and benign prostatic hypertrophy. Vital signs show his temperature is 36.8 C (98.2 F), pulse is 76 beats/minute, respiratory rate is 12 breaths/minute, and blood pressure is 118/70 mmHg. His weight is 129.2 kg (285 lbs) and his body mass index (BMI) is 41. Which of his co-morbidities is most likely to be associated with his BMI?
A. Atrial fibrillation B. Benign prostatic hypertrophy C. Chronic allergic rhinitis D. Osteoporosis E. Psoriasis
The correct answer is A.
Obese patients are at a significantly increased risk for developing atrial fibrillation. This is thought to be related to increased left-atrial volume. Weight loss may reduce the burden of atrial fibrillation in obese patients. Also, obesity has been associated with COPD and asthma, although the nature of the association has not been fully elucidated. Additional related health risks include atherosclerotic cardiovascular disease (including stroke, coronary artery disease, and peripheral vascular disease) and heart failure.
Psoriasis, chronic allergic rhinitis, and benign prostatic hypertrophy are less likely to be associated with obesity.
Osteoporosis is associated with low BMI, not obesity.
